Failure to Use Required Gown Under Enhanced Barrier Precautions During Wound Care
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during wound care. A male resident with multiple diagnoses, including a stage IV pressure ulcer to the left calf present on admission, diabetes, osteoarthritis, and coronary atherosclerosis, was care planned for EBP. The care plan specified that staff must use a gown and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. The resident’s MDS indicated he was usually able to understand and be understood by others and had a BIMS score of 11, indicating moderate cognitive impairment. During an observation, the Treatment Nurse performed wound care on this resident without donning a gown, despite EBP personal protective equipment (PPE) being available outside the room. The nurse knocked, explained the procedure, performed hand hygiene, opened supplies, and wore gloves, but did not put on a gown while removing the old dressing, cleansing the wound, and applying new dressings. After completing the procedure, the nurse disposed of trash, removed gloves, and performed hand hygiene. In an interview, the Treatment Nurse acknowledged that residents with wounds required EBP, including gowns and gloves, and stated she did not wear the gown because it “slipped her mind.” The DON confirmed that EBP was required for residents with chronic wounds and that EBP for wound care always included a gown and gloves, with goggles or face shield if splashing was anticipated. The facility’s EBP policy stated that EBP is an infection control intervention using targeted gown and glove use during high-contact resident activities to reduce MDRO transmission.
Penalty
Resources
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Surveyors found that staff were not disinfecting glucometers according to the manufacturer’s instructions and facility policy. The policy required cleaning before and after use and at storage using an EPA-registered disinfectant wipe, such as bleach wipes, with sufficient contact time on all external surfaces. Instead, two LPNs reported and demonstrated using alcohol wipes to clean glucometers after use, allowing them to air dry, and then storing them on the med cart, despite bleach wipes being available. The NHA stated that staff were expected to follow the policy, confirming that these practices did not comply with the required infection control procedures.
Surveyors identified multiple infection control failures involving three residents. During tracheostomy care for a resident with chronic respiratory failure and a trach, an RN removed soiled gloves after handling the inner cannula and dressing and then donned sterile gloves without performing required hand hygiene between glove changes before cleaning the stoma and applying a new dressing. In a separate incident, an RN performed a finger-stick blood glucose test on a diabetic resident using a shared glucometer and returned the device to the medication cart without disinfecting it, despite facility policy requiring decontamination of shared glucometers. Additionally, a resident with an indwelling urinary catheter was observed seated with the catheter drainage bag lying directly on the floor, contrary to facility policy that catheter bags and tubing be kept off the floor.
A resident receiving IV meropenem via a PICC line for septic shock related to a UTI had an active care plan and door signage requiring enhanced barrier precautions, including use of gown and gloves for high-contact care and device care to reduce MDRO transmission. During an observed medication administration, an LPN performed hand hygiene, donned gloves, accessed and flushed the PICC line, and administered the antibiotic without donning a gown, later stating she had forgotten to do so. The IP confirmed that a gown was required before administering the antibiotic, and this failure created the potential for infection spread.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
Surveyors found that residents were served meals in the dining room without being offered required hand hygiene before eating, despite facility policy mandating handwashing or alcohol-based hand rub use before handling food. A CNA and the DON both acknowledged that residents’ hands should have been sanitized prior to meals. Additional observations showed a housekeeper transporting clean gowns uncovered in a hallway and significant visible buildup of white and grey fuzzy substances on pipes, wires, equipment, and chemical buckets in the laundry area, with the housekeeper stating there was no formal cleaning schedule in place.
Improper Glucometer Disinfection Practices Contrary to Manufacturer Instructions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper cleaning and disinfection of glucometers on two of three nursing units reviewed. The facility’s policy, last reviewed March 23, 2026, required that glucometers be cleaned per the manufacturer’s instructions before use, after use, and when stored. The manufacturer’s instructions for the specific glucometer brand in use directed staff to use an EPA-registered disinfectant wipe, such as bleach wipes, on all external surfaces of the device, including the front, back, and sides, and to ensure the surface remained wet for the required contact time of about four minutes. These requirements were in place to support the facility’s infection prevention and control program under the cited regulatory standards. During interviews and observations, surveyors found that nursing staff were not following these established procedures. One LPN demonstrated her usual process by cleaning the glucometer after use with alcohol wipes, placing it on the medication cart to air dry, and then storing it back in the cart. When presented with a container of bleach wipes from the medication cart, this LPN acknowledged their availability and stated she “probably should use these” but preferred alcohol wipes. Another LPN reported that after using the glucometer, she wiped it down with alcohol wipes, allowed it to air dry, and then stored it in the medication cart. In a subsequent interview, the Nursing Home Administrator stated that she expected staff to follow the facility’s policy, confirming that the observed and reported practices were inconsistent with the manufacturer’s instructions and the facility’s written standards for glucometer disinfection.
Plan Of Correction
1. Glucometers were cleaned per manufacturer's instructions following observation during state survey 2. Ensured proper disinfectant wipes used for cleaning glucometers were available in nursing carts. 3. Education provided to licensed nursing staff on cleaning and disinfecting the glucometers after use. 4. Audit to be completed of proper glucometer cleaning during medication pass 3 times a week on random shifts x 1 month, 2 times a week for 1 month and then 1 time a week X 1 month. Audits will be taken to QAPI for further recommendations for quality assurance and performance improvement.
Infection Control Failures in Tracheostomy Care, Glucometer Disinfection, and Catheter Management
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices related to respiratory care, blood glucose monitoring, and indwelling urinary catheter management. One resident with chronic respiratory failure, COPD, asthma, chronic pulmonary edema, and a tracheostomy had physician orders for tracheostomy care every shift and a daily inner cannula change. During an observed tracheostomy care procedure, the RN donned PPE, washed her hands, and set up supplies, then removed the old inner cannula and dressing with gloved hands and disposed of them. After this, she removed her gloves and immediately donned a new pair of sterile gloves from the tracheostomy care kit without performing hand hygiene in between glove changes, then proceeded to clean around the tracheostomy stoma and apply a new split gauze dressing. The RN later confirmed she had not performed hand hygiene between glove removal and donning new gloves, despite the facility’s tracheostomy care policy requiring hand hygiene at that point. Another deficiency occurred during blood glucose monitoring for a resident with intact cognition, diabetes, morbid obesity, chronic kidney disease stage 5, and atherosclerotic heart disease, who used a walker and received insulin. An RN entered the resident’s room to check blood sugar, initially using the resident’s Dexcom G7 receiver, then obtained consent to perform a finger-stick blood glucose test. After completing the finger stick with a shared glucometer, the RN returned to the cart, placed the glucometer on the cart, unlocked the cart, and stored the glucometer inside without disinfecting it. The RN later confirmed that the glucometer was not cleaned after use and acknowledged that it should have been disinfected after use on this resident, as it was a shared device used for multiple residents on the same hall. Facility policy required the glucometer to be disinfected on all external parts following the disinfectant’s directions. A further deficiency was identified in the management of an indwelling urinary catheter for a resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus. The resident had a care plan indicating risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention, with goals that the resident show no signs or symptoms of urinary infection and that the catheter remain patent and without complications. Interventions included ensuring the catheter tubing and drainage bag were secured properly with a dignity cover in place. Physician orders directed that the #16 French indwelling catheter be changed every 30 days and as needed, and the MDS confirmed the catheter was in place. During observation, the resident was seated in a chair with the catheter bag lying directly on the floor, with no barrier in place. An LPN confirmed that the catheter bag was on the floor. The facility’s catheter-associated urinary tract infection prevention policy specified that catheter bags and tubing should be kept off the floor.
Plan Of Correction
Formatted text (without <text> tags or quotes): 1. On 5/6/26 Resident #9 was assessed by Director of Nursing and shows no ill effect related to the lack of hand hygiene after removing the inner cannula and split gauze dressing. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. Resident #19 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. Resident #28 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. Resident #79 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. 2. Like Residents are identified as residents who utilize a tracheostomy and no other like resident were identified. An audit will be completed by the Director of Nursing or designee utilizing the Trach Tube Cannula and Stoma Care Skills check off which were created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure licensed nurses are preforming tracheostomy care according to the facility policy. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are located below the bladder but not laying on the floor. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize a facility glucometer. An audit will be completed by the Director of Nursing or designee utilizing the Glucometer Decontamination Skills check-off which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure licensed nurses are disinfecting glucometers after use according to the facility policy. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the tracheostomy tube cannula and stoma care policy to include hand hygiene during the procedure and hand hygiene with glove changes. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy to include placement of urinary catheter bags. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Glucometer and PT/INR Decontamination Policy to include disinfecting the glucometer after use. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with tracheostomies to ensure licensed nurses are performing tracheostomy care according to the facility policy. This audit will be completed weekly for 4 weeks, beginning 5/14/26 to ensure licensed nurses are performing tracheostomy care according to the facility policy. Noncompliance noted during the audits will be corrected with licensed nurse re-educated with return demonstration. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, Director of Nursing or designee will complete an audit of all residents who utilize urinary catheters to ensure catheter bags are located below the bladder but not laying on the floor. This audit will be completed weekly for 4 weeks, beginning 5/14/26 to ensure catheter bags are located below the bladder but not laying on the floor. Noncompliance noted during audits will be corrected with catheter bags changed and relocated to below the bladder but not laying on the floor. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Glucometer Decontamination Skills check-off which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete 5 observations of licensed nurses weekly for 4 weeks, beginning 5/14/26 to ensure the glucometer is disinfected appropriately after use. Noncompliance noted during audits will be corrected with the glucometer disinfected appropriately after use. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Use Required Enhanced Barrier Precautions During PICC Line Medication Administration
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident receiving IV antibiotic therapy via a PICC line, as required by the resident’s care plan and posted signage. The resident, admitted with diagnoses including nicotine dependence, hypertension, anxiety, and insomnia, had a physician’s order for meropenem IV three times daily for septic shock related to a urinary tract infection. A care plan revised on 4/12/26 documented that the resident was on enhanced barrier precautions to reduce the risk of MDRO transmission related to the PICC, directing staff to use gowns and gloves when performing high-contact resident care or device care. Enhanced Barrier Precaution signage was posted on the resident’s door. On 4/14/26 at 3:39 PM, during an observed medication pass, an LPN entered the resident’s room with meropenem, performed hand hygiene, and donned gloves, then sanitized the PICC line needle connector cap, flushed the line with normal saline, and administered the meropenem without donning a gown. The LPN later stated she forgot to put on the gown and acknowledged she should have worn it before accessing the PICC line. The Infection Preventionist confirmed that a gown was required prior to administering the antibiotic and that the nurse should have worn a gown. This deficient practice created the potential for the spread of infection and its associated complications.
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inadequate Hand Hygiene and Environmental Cleaning in Infection Control Program
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to hand hygiene and maintaining a clean, sanitary environment. The facility’s Handwashing/Hand Hygiene Policy, revised March 2022, required use of alcohol-based hand rub or soap and water before and after eating or handling food. During a meal service observed at 12:04 PM on 4/12/26, 14 residents were served meals in the dining room without being offered hand hygiene before eating. At 12:12 PM, a CNA acknowledged that residents’ hands should have been sanitized before they started eating, and on 4/13/26 at 2:44 PM, the DON confirmed that residents in the dining room should have been offered hand hygiene using hand sanitizer from a bottle before meals. Additional infection control concerns were observed regarding environmental cleanliness and handling of clean items. On 4/14/26 at 6:53 AM, a housekeeper was seen carrying clean gowns down the hallway uncovered, and at 6:56 AM the housekeeper stated the gowns should have been covered. Later that morning at 8:36 AM, with the housekeeper present, surveyors observed multiple areas of visible buildup and residue in the laundry room, including a white hard substance and grey fuzzy substance on pipes behind a small washing machine, a tube of wires covered with grey fuzzy substance near the entrance, teal-colored and grey fuzzy substances on water pipes behind a large washing machine, a layer of white substance on the chemical dispenser cover, and grey fuzzy buildup on chemical buckets and nearby walls. At 8:41 AM, the housekeeper reported there was no cleaning schedule for the laundry room, although sweeping was done daily.
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